Clinical Insights from Day 3 of the Elevate-Derm PA-NP Conference in Boston, Massachusetts

Update on Alopecia Areata (Jerry Shapiro, MD)

• ● Alopecia areata can involve any hai-bearing surface, such as beard, eyebrow, eyelash, axillary, or pubic area.
  
• ● Exclamation point hairs are indicative of active alopecia areata.
  
• ● Alopecia areata targets dark hairs and spares gray hairs. Pitted nails may or may not be seen in
  alopecia areata.
  
• ● Ophiasis alopecia areata is characterized by hairloss in the back of the head and it can be more
  refractory to treatment.
  
• ● The Severity of Alopecia Tool (SALT) score is a scale that measures the percentage of scalp hair
  loss. A score of greater or equal to fifty percent hair loss is necessary for insurance to cover a
  Janus Kinase inhibitor.
  
• ● Deuruxolitinib is a Janus Kinase 1/Janus Kinase 2 pathway inhibitor that was just approved for
  the treatment of alopecia areata.

Who Cares about Conference Posters? Your Patients Do! (Douglas DiRuggiero, PA-C)

• ● Abstracts from posters often get reprinted. Once an abstract is printed it becomes a publication, which can advance your reach as an advanced practice provider.
  
• ● Posters are not expensive and can yield many benefits to the medical community.
  
• ● A recent poster from apremilast showed that delaying systemic treatment in psoriasis patients
  leads to delayed quality of life improvement and exacerbated psoriasis flares.
  
• ● A poster discussing generalized pustular psoriasis (GPP) suggests that untreated GPP negatively
  affects patients even in the absence of a flare event and that treatment with sepesolimab at 300mg every four weeks can prevent flare ups.

It Still Exists! A Hansen's Disease Primer for the Non-Leprologist (Adam Lipworth, MD)

• ● Hansen’s disease is still prevalent worldwide and present in the United States. It is hard to diagnose and diagnosis is often delayed.
  
• ● Delayed diagnosis of Hansen's disease can lead to severe and permanent morbidity.
  
• ● 95% of people are naturally immune to Hansen's Disease.
  
• ● In tuberculoid leprosy, there is only one or a few lesions and plaques are anaesthetic and
  anhidrotic. There are thickened nerves near the plaques.
  
• ● In lepromatous leprosy, there are many diffuse lesions that have normal sensation, but there is
  symmetric neuropathy from larger nerve damage.
  
• ● Diagnosis World Health Organization Criteria (consider a diagnosis of Hansen's disease if 2 out
  of 3 are present):
  1. Definite anesthesia of hypopigmented or reddish patch.
  2. Thickened/enlarged peripheral nerve w/neuropathy of region supplied by the nerve.
  3.-Acid fast bacilli on slit-skin smear.

Hair Disorders - How I Treat the Hard Stuff (Jerry Shapiro, MD)

• ● Trichoscopic evaluation for Lichen planopilaris shows a loss of follicular ostia, pigment incontinence (blue-gray dots) and perifollicular scaling.
  
• ● Scarring alopecia subtypes include lymphocytic, neutrophilic, and mixed.
  
• ● There may be an association between chemical sunscreen use and frontal fibrosing alopecia. Recommend sunscreens with zinc oxide and avoid chemical sunscreens.
  
• ● Mesotherapy with Dutasteride is an option in the treatment of androgenetic alopecia and has minimal side effects.
  
• ● Pioglitazone is an oral medication that can be used to treat lichen planopilaris. It normalizes cholesterol synthesis within the sebaceous gland of the follicle allowing for the creation of a more functional hair shaft.
  
• ● Central Serous Chorioretinopathy, which is the accumulation of fluid under the retina, can occur after intralesional triamcinolone injections in the scalp.

Lab Monitoring Requirements in Injectable Biologic/Small Molecule Patients (G. Michael Lewitt, MD)

• ● Though no lab testing is required with janus kinase inhibitors, it is advisable to check a full lipid panel and liver function tests at week 6-8 and annually thereafter in addition to an annual tuberculosis test.
  
• ● Providers need to use judgment when screening/monitoring patients on biologics. There are not detailed lab requirements for many of the biologic medications.
  
• ● Be mindful about patients that may be on combination therapies with a "traditional immunosuppressant" like methotrexate that require additional or more frequent lab testing.

Treating Psoriasis in Special Populations (G. Michael Lewitt, MD)

• ● All FDA-approved biologics package inserts recommend/require a baseline tuberculosis screening.
  
• ● Latent tuberculosis in the biologic patient: TNF-⍺ and IL-12/23 inhibitors can be used after one month of prophylaxis.
  
• ● Interruption of antipsoriatic oral and biologic therapies is generally not necessary for patients receiving non-live vaccines. Temporary interruption of oral and biologic therapies before and after administration on live vaccines is recommended in most cases.
  
• ● Tumor necrosis factor alpha (TNF-⍺) inhibitors can reactivate hepatitis B virus. Consult hepatology in patients with a history of hepatitis B for potential prophylaxis prior to starting a biologic.
  
• ● Patients on abatacept, a CTLA-4 fusion protein used to treat patients with severe rheumatoid arthritis, are at increased risk of developing melanoma.
  
• ● Discontinuation of biologics is recommended for two to three half lives of the medication before and after live vaccinations.

Roadblock: Challenges of Obtaining a Biologic/Small Molecule drug (G. Michael Lewitt, MD)

• ● Dermatology providers are disproportionately affected by prior authorizations due to price advances in biologic medications and previous inexpensive generic medications.
  
• ● Be sure to document appropriate rating scales (Investigator's Gobal Assessment, Body Surface Area, Eczema Area and Severity Index, Psoriasis Area and Severity Index, etc.) and affected special areas in chart notes to help get medications covered by insurance.
  
• ● Communicate tips/tricks to get medications covered with colleagues.
  

Mechanisms of Chronic Urticaria (Aaron Ver Heul, MD)

• ● The key feature of urticarial lesions is evanescence (lasts less than 24 hours and does not leave scars or discoloration).
  
• ● Beware of urticarial lesions that are primarily painful or do not itch. If that happens consider a diagnosis of urticarial vasculitis or autoinflammatory diseases.
  
• ● Alpha-gal syndrome is a food allergy to mammalian meat that develops from a tick bite (lone star tick). It can be different from other food allergies because the allergic reaction can be delayed.
  
• ● If urticarial lesions are lasting more than 48 hours, a biopsy can be helpful to rule out urticarial vasculitis or an early bullous pemphigoid.
  
• ● Mas-related G protein-coupled receptor X2 or MRGPRX2 is a receptor found on mast cells that plays a role in host defense and allergic inflammation. Its activation can trigger mast cell degranulation, chemotaxis and cytokine release. It is involved in chronic urticaria.

Managing Chronic Urticaria: How I do it (Aaron Ver Heul, MD)

• ● Allergy testing is appropriate if there is a consistent, rapid reaction after an exposure to a substance.
  
• ● Without a clinical history used for targeted allergy testing (especially for food allergy), the specificity of a positive test is approximately 0.5.
  
• ● All second generation antihistamines have been proven safe to be taken up to four times daily.
  
• ● The prevalence of autoimmune diseases in patients with chronic spontaneous urticaria increases
  over time, suggesting chronic spontaneous urticaria might precede the development of other autoimmune diseases.
  
• ● Omalizumab has a risk of paradoxical anaphylaxis, which is why chronic spontaneous urticaria is often managed by an allergist.

Cases from my Career: Lessons Learned from my Itchy Patients (Aaron Ver Heul, MD)

• ● Medications that can cause itching include calcium channel blockers, hydrochlorothiazide, and opioids.
  
• ● In the United States, prurigo nodularis is defined as a distinct clinical disease defined by the presence of chronic pruritus and multiple localized or generalized, elevated, firm and nodular lesions.
  
• ● Look for clues of histaminergic response/mast cell-mediated etiology even when not a classical presentation of chronic spontaneous urticaria.
  
• ● If a patient is sensitized to an allergen, they will have a positive serum IgE. If the serum IgE is negative but the patient still reacts, it's considered an intolerance.
  

Infectious-Disease Dermatology Management Update: Complex Choices for Common Conditions Part 1 (Adam Lipworth, MD)

• ● If bullous impetigo is the suspected diagnosis, aspirate fluid from bullae to use for gram stain to confirm diagnosis. Gram positive cocci should be seen in clusters if diagnosis is bullous impetigo.
  
• ● For furunculosis greater than one centimeter diameter, treat with incision and drainage and consider an anti-staphylococcus antibiotic.
  
• ● Tenderness is the most sensitive characteristic of cellulitis.
  

Infectious-Disease Dermatology Management Update: Complex Choices for Common Conditions Part 2 (Adam Lipworth, MD)

• ● Retiform purpura comes from occlusion of the perforating arterioles and has a characteristic appearance of purpuric patches with jagged edges.
  
• ● It is prudent to recognize retiform purpura, as it is an early indicator of a systemic, generally malignant process.
  
• ● If a tick with black legs (most consistent with appearance of a deer tick) has been embedded on a patient for at least 36 hours (engorged appearance), remove the tick and then prescribe doxycycline 200mg to take once to prevent tick borne disease.